Prospective Study
Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Surg. Mar 27, 2019; 11(3): 169-178
Published online Mar 27, 2019. doi: 10.4240/wjgs.v11.i3.169
Learning curve of enhanced recovery after surgery program in open colorectal surgery
Varut Lohsiriwat
Varut Lohsiriwat, Division of Colon and Rectal Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
Author contributions: Lohsiriwat V solely contributed to this study and wrote the manuscript.
Institutional review board statement: The study was approved by the institutional ethics committee (Si 498/2017).
Informed consent statement: All the participants provided written consent to participate in the study. The identity of the subjects was omitted and anonymized.
Conflict-of-interest statement: The author declared that I had no conflict of interest.
CONSORT 2010 statement: This study report was in compliance with the CONSORT 2010 statement
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Varut Lohsiriwat, MD, PhD, Associate Professor of Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand.
Telephone: +66-2-4198005 Fax: +66-2-4121370
Received: February 20, 2019
Peer-review started: February 20, 2019
First decision: February 26, 2019
Revised: March 2, 2019
Accepted: March 20, 2019
Article in press: March 20, 2019
Published online: March 27, 2019
Research background

Enhanced recovery after surgery (ERAS) reduces hospitalization and complication following colorectal surgery. Whether the experience of multidisciplinary ERAS team affects patients’ outcomes is unknown especially for open colorectal surgery – which is known to be associated with higher rates of complication and more difficulty to implement an ERAS program than laparoscopic surgery.

Research motivation

The initial stage of ERAS application into surgical practice, i.e., learning curve, could be a crucial phase of this patient-centered perioperative pathway because the workflow of heath care personals needs to be adopted and the guideline has to assimilate into a daily practice.

Research objectives

This study aimed to evaluate and establish a learning curve of ERAS program for open colorectal surgery.

Research methods

This was a review of prospectively collected database of 380 “unselected” patients undergoing elective “open” colectomy and/or proctectomy under ERAS protocol from 2011 (commencing ERAS application) to 2017 in a university hospital. Patients were divided into 5 chronological groups (76 cases per quintile). Surgical outcomes and ERAS compliance among quintiles were compared. Learning curves were calculated based on criteria of optimal recovery: defined as absence of major postoperative complications, discharge by postoperative day 5, and no 30-d readmission.

Research results

Hospitalization more than 5 d occurred in 22.6% (n = 86), major complication was present in 2.9% (n = 11) and 30-d readmission rate was 2.4% (n = 9) accounting for unsuccessful recovery of 25% (n = 95). Conversely, the overall rate of optimal recovery was 75%. The optimal recovery significantly increased from 57.9% in 1st quintile to 72.4%-85.5% in the following quintiles (P < 0.001). Average compliance with ERAS protocol gradually increased over the time - from 68.6% in 1st quintile to 75.5% in 5th quintile (P < 0.001). The application of preoperative counseling, nutrition support, goal-directed fluid therapy, O-ring wound protector and scheduled mobilization significantly increased over the study period.

Research conclusions

A number of 76 colorectal operations are required for a multidisciplinary team to achieve a significantly higher rate of optimal recovery and high compliance with ERAS program for open colorectal surgery.

Research perspectives

These findings could call surgical communities to find the best ways to shorten the learning curve of ERAS program – especially in open laparotomy. The barriers to the conduct, application and maintenance of ERAS program for colorectal surgery should be identified and solved systematically in order to achieve the best care and optimal recovery of surgical patients.